Nyack Ambulance COVID-19 Health Survey

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This Form Is REQUIRED To Be Completed By Each Employee on Each Day of Work

Employee Name *

Shift Date *

YYYY

Shift Time(s) - Select ALL Shift's Your Scheduled For TODAY *

0100-0700hrs on the Date Above

0700-1300hrs on the Date Above

1300-1900hrs on the Date Above

1900-0100hrs Ending on the NEXT day

Second Rig or Building Meeting

Other

Required

You are being asked to answer this questionnaire in order to determine whether you are experiencing any symptoms that could be consistent with COVID-19. This is being done solely for the purpose of protecting your workplace from potential spread of the disease. Any results you get, and/or any directive you receive to stay home, does not constitute a diagnosis of COVID-19, nor are we advising you whether you need to get tested or contact a physician. By clicking Accept you're stating that you understand that you are going to take the Nyack Ambulance Symptom Check survey that we will rely on to permit safe entry into our facility. You certify that you will answer each question truthfully, and to the best of your ability. *

I Do NOT Agree with Declaration

I Agree with Declaration

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